Healthcare Provider Details

I. General information

NPI: 1619710761
Provider Name (Legal Business Name): KHOSROW DAVACHI MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 OLD BRANCH AVE STE D203
CLINTON MD
20735-1611
US

IV. Provider business mailing address

7700 OLD BRANCH AVE STE D203
CLINTON MD
20735-1611
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-7121
  • Fax: 301-868-7968
Mailing address:
  • Phone: 301-868-7121
  • Fax: 301-868-7968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: KHOSROW DAVACHI
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 301-868-7121